Andreia Fernandes Azevedo

O Programa de Intervenção Parental ‘Anos Incríveis’:

Eficácia numa amostra de crianças portuguesas de idade pré-escolar com comportamentos de PH/DA

Tese de Doutoramento em Psicologia orientada pela Professora Doutora Maria

João Seabra Santos e pela Professora Doutora Maria Filomena Gaspar,

apresentada à Faculdade de Psicologia e Ciências da Educação da

Universidade de Coimbra

3 de dezembro de 2013

The Incredible Years Parenting Programme:

Efficacy in a sample of Portuguese pre-school age children with AD/HD behaviours

The studies presented in this thesis were carried out at the Faculty of Psychology and Educational Sciences,

University of Coimbra, Portugal, and were supported by a personal fellowship from the

Portuguese Foundation for Science and Technology (FCT: SFRH/BD/40339/2007)

and by a project grant supported by FCT and Compete-Feder:

Early prevention/intervention in disruptive behaviour disorders: Efficacy of parents and teacher programmes [Grant number: PTDC/PSI-PED/102556/2008]

Overview of Presentation

Introduction

Rationale for the Study

Study Aims

Methods

Results

Discussion

Implications

Introduction

AD/HD in Preschool Years

Symptoms of hyperactivity, impulsivity and/or inattention can emerge early in

preschool years

Cause impairment for the child , family, school

Can be moderately persistent over time Harvey et al., 2009

Increase risk for further negative long-term difficulties DuPaul et al., 2001

Predict the development of comorbid problems (ODD, CD)

High developmental changes in this age period:

Careful staged approach to identification/intervention Sayal et al., 2012

Comprehensive and multidisciplinary assessment

Preschool years: critical moment for early identification/intervention and

prime target of investment (clinicians, policies)

Introduction

Prevention of negative developmental pathways

AD/HD in Preschool Years

• Negative parent-child interactions

• Dysfunctional parenting

• Low sense of competence

• Stress, marital problems

• Parental psychopathology

• Poorly self-regulated children

(difficulty in listening, paying

attention,…)

Genes X Environmental risk factors

Multiple pathways from risk to disorder Sonuga-Barke et al., 2005

Family

Social

Environment/

Community

Child

• Bidirectional and

reciprocal influences

• Coercive cycle

Potential risk factors

Target PARENTS in early effective intervention

Introduction

Psychosocial Intervention: Parenting Programmes

Evidence-based psychosocial interventions - BPT strongly recommended as

first-line intervention for preschool-age children with or at-risk of AD/HD

AAP, 2011; Charach et al., 2011

Introduction

Psychopharmacological intervention: children with severe symptoms;

after a BPT intervention

PATS Study: effects lower than in school age-children; increased side

effects; limited data of long-term impact; parents concerns and ethical issues

Kollins et al., , 2006; Wigal et al., 2006

Need of effective nonpharmacological intervention for preschool years

Rationale for the Study

Why this Study?

Study Rationale

What do we know from literature and research ? What we tried to

accomplish ?

Early intervention in AD/HD, possibly more efficacious in

preschool children Sonuga-Barke et al., 2006

Before association with secondary negative outcomes

Children´s behaviour more prone to change

Parents socialization role

Target early intervention

Evidence of PT short-term effectiveness (RCTs)

e.g., Bor et al., 2002; Jones et al., 2007; Thompson et al., 2009; Webster-Stratton et al., 2011

Examine PT effectiveness

in a Portuguese sample

Growing evidence that effects can be sustained over time

Rajwan et al., 2012

Evaluate 12-month

effects: enlarge support

Why the Incredible Years Parenting Programme?

• Widely researched (↑ 30 years), empirically supported (replicated ) psychosocial

intervention for behaviour problems

Recent research: IY is effective for pre-schoolers with AD/HD

Jones et al., 2007; Webster-Stratton et al., 2011

Target different systems (ecological perspective of child problems)

IY previously translated and implemented in Portugal Webster-Stratton et al., 2012

Need of evidence-based interventions in Portugal

Study Rationale

Study Aims

Main Purpose

Evaluate IY short and medium-term efficacy (6 and 12-months

after baseline) in reducing hyperactive behaviours

Study 1

Study 2

Analyse the maintenance of post-intervention effects

(at 12-month FU)

Study 2

Explore the differences in 12-month changes between two groups

of children with different levels of initial hyperactivity behaviour

Study 3

Examine mothers’ attendance, satisfaction and IY acceptability Study 1

and 3

Study Aims

Methods

Study design

Participants

Procedures

Instruments

Intervention

Study Design

Methods

Time/Assessment Screening

Main trial

T1

Pre-assessment Baseline

Randomization (3:2)

Intervention

Group

IYG (n = 52)

Control Group

WLG (n = 48)

IY

AD/HD

subsample T2

Post- assessment (6 M)

n = 50

n = 37

IY

T3

Follow-up assessment (12 M) n = 44

Lo

ng

itu

din

al

Stu

dy

Screening

Methods

Clinically referred (psychologist, paediatrician,

child psychiatrist)

n = 54

Pre-school

screening

n = 9

Blog, newspaper

advertisement,

other parents

n = 37

Community referred

Inclusion Exclusion Criteria

Methods

• 3 – 6 years old

• SDQ-HY or CP ≥ Portuguese borderline cut-offs

• WWPAS ≥ Portuguese at-risk cut-off (80th percentile)

Inclusion

Criteria

• Diagnosis of neurological or developmental disorder (autism)

and severe developmental delay

• Pharmacological or psychotherapeutic intervention

Exclusion

Criteria

Participants

Methods

Child Variables IYG WLC

Socio-demographic data

Age (months) 55.92±10.9 55.71±11.03

Gender (male) 71% 73%

Clinical Characteristics

AD/HD behaviors

WWPAS ( ≥ 95th percentile) 65% 58%

PKBS-O/I (85th to 94th percentile) 29% 30%

PKBS-O/I ( ≥ 95th percentile) 56% 49%

Social Skills

PKBS-SS ( ≤ 15th percentile) 63% 56%

Oppositional/aggressive comorbid behaviour s 79% 70%

Participants

Methods

Primary Caregiver (Mother): Variables IYG WLC

Socio-demographic data

Mother 92% 96%

Age (years) 36.37±5.66 34.65±5.94

Marital Status: Married/as married 83% 73%

Years of education 13.9±3.89 13.55±3.6

Family SESª: Medium 42% 48%

Clinical Characteristics

Depressive symptoms (≥ 17) 23% 29%

AD/HD symptoms (≥ 9 symptoms score) 15% 21%

Procedures

Methods

Authorizations Author’s approval for using the programme

Ethical

Approvement

Portuguese National Committee of Data Protection (CNPD)

Medical Ethical Committee

Informed Consent Written consent to take part of a RCT

Preliminary Study Pilot-study

Study Procedures

Dissemination

Screening

First interview: researcher

Baseline assessment: independent trained evaluators (blind)

Randomization: researcher

T2 and T3 assessments: independent trained evaluators

Instruments

Methods

Children Behaviour: Mothers’ and Teachers’ Reported Measures

Werry-Weiss-Peters Activity Scale (WWPAS) Routh, 1978

Preschool and Kindergarten Behavior Scales – 2nd Edition (PKBS-2) Merrell, 2002; Major, 2011

Children Behaviour: Mother’s Interview

Parental Account of Childhood Symptoms (PACS) Taylor et al., 1986

Sense of Competence, Parenting Practices, Psychological Adjustment: Self-Reported Measures

Parenting Sense of Competence Scale (PSOC) Johnston & Mash, 1989

Parenting Scale (PS) Arnold et al., 1993

Beck Depression Inventory (BDI) Beck et al., 1961; Vaz Serra & Pio Abreu, 1973

Instruments

Methods

Mother-Child Interaction Behaviours : Observation Measure

Dyadic Parent-Child Interaction Coding System (DPICS) Eyberg & Robinson, 1981

Programme Satisfaction: Self-reported Measures

Weekly Satisfaction Questionnaire Webster-Stratton, 2001

Final Satisfaction Questionnaire Webster-Stratton, 2001

Intervention

Methods

Aims ( ↑ protetive factors ↓ risk factors)

• Strengthen parent-child relationships • Increase parents’ nurturing, positive parenting skills and confidence • Improve parents skills of emotional, social, persistence coaching • Encourage effective limit setting, use of non-violent discipline strategies • Encourage child cooperation and self-regulation • Increase family support and strenghten family-school relations

Groups of 9 to 12 parents

2 trained group facilitators (total=6)

14 weeks + 2 booster sessions (9 and 15 months after baseline)

2 hours in the evening: university service or mental health centre

Childcare, snacks, make-up sessions

Intervention

Methods

Topics

• Play ; descriptive comments ; praise ; rewards; household rules; routines; clear commands; parents’ calming thoughts; ignoring; time-out ; consequences ; problem solving

• Main idea: Strong foundations – use liberally; Top – use selectively

Strategies: Multiple method approach

• Role-play - practice; video analysis; brainstorming; group

discussion of different topics; buzzes; reading materials;

completing handouts; buddy calls; leaders’ call

Results

Pre-Post Comparison: Study 1

Results

Preliminary analysis: baseline

• No significant differences between groups (IYG vs WLG), except DPICS

coaching variable (IYG > WLG)

Attrition

• T2 = retention of 87% total participants (IYG > WLG): 100/87

• T3 = retention 85% of IYG participants: 52/50/44

Attrition

21

23

25

27

29

31

33T1 T2

80

82

84

86

88

90

92

85

87

89

91

93

95

97

Pre-Post Comparison: Study 1 (children variables)

Results Repeated measures GLM; Group: between-subjects; Time: within-subjects

WWPAS: p < .01,

p² = .11

PKBS-O/I_home: p < .01,

p² = .11

PKBS-O/I_school: p < .05,

p² = .06

PKBS-SS_home: p = .052,

p² = .04

Statistical Significant interaction effects (group X time):

Decrease of reported attention-deficit/hyperactivity behaviours at home and at school:

IYG > WLG

Statistical Marginal interaction effects (group X time):

Marginal increase on reported (home)/observed social skills: IYG > WLG DPICS-CPS: p = .053,

p² = .06

6

8

10

12

14

16

18

20

22

24

IYG

WLG

Pre-Post Comparison: Study 1 (mothers’ variables)

Results Repeated measures GLM; Group: between-subjects; Time: within-subjects

Statistical Significant interaction effects (group X time):

Decrease of mothers’ self-reported dysfunctional discipline practices (IYG < WLC)

Increase of mothers’ self-reported sense of competence (IYG >WLC)

Increase of mothers’ observed positive parenting and coaching skills (IYG > WLC)

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,7

3,8

52

54

56

58

60

62

64

13

15

17

19

21

23

25

27

29

12

14

16

18

20

22

24

26

IYG

WLG

PS: p < .001,

p² = .19

PSOC: p < .05,

p² = .05 DPICS_PP: p < .001,

p² = .21

DPICS_COACH:

p < .05, p² = .06

12-month effects: Study 2 (children variables)

Results Repeated measures GLM; Time: within-subjects

:

Maintenance of intervention effects (time effect):

Changes remained stable, no significant statistical differences between T2-T3 (ES: <.01 to .05)

Exception: Significant statistical decrease in children AD/HD behaviours (mother’s

interview) from T2 to T3

WWPAS: p < .001, p² = .44

WWPAS_T2-T3: p =.536, ns

PACS-HY: p <.001, p² = .35

PACS-HY_T2-T3: p = .011, p² = .12

PKBS-SS: p < .001, p² = .32

PKBS-SS: p = .111, ns

12-month effects: Study 2(mothers’ variables)

Results: Repeated measures GLM; Time: within-subjects

:

Maintenance of intervention effects over time (time effect):

Changes remained stable, no significant statistical differences between T2-T3 (ES: <.01 to .02)

Exception: Significance decrease on observed coaching skills from T2 to T3 (effect faded

out by 12 months)

PS: p < .001, p² = .49

PS_T2-T3: p = .337, ns

PSOC: p < .001, p² = .20

PSOC_T2-T3: p = .900, ns

DPICS-PP: p < .001, p² = .23

DPICS-PP_T2-T3: p = .813, ns

DPICS-COACH: p = .407, ns

Clinical Significant Reduction of AD/HD behaviours: Study 1 + Study 2

Results Non-parametric tests

30% reduction of initial baseline scores = clinically significant improvement

59% IYG (12 month follow-up)

Axberg et al., 2007; Webster-Stratton et al., 1989

43% IYG vs 11% WLG (6 month follow-up) [χ² (1) = 11.66; p =.003]

Low and High-Hyperactivity at baseline: Study 3

Results Mann-Whitney U test; Group high or low-hyp: between-subjects

[WWPAS: p = .008]

12.33

6.57

[PACS-HI: p = .055]

Groups equivalent at baseline, except for AD/HD behaviours (High > Low)

All children improved, but significant differences in changes (T1-T3) on AD/HD

behaviours, overreactivity parent practices, and depressive symptoms between groups:

High > Low

0

5

10

15

20

25

30

35

High-Hyp Low-Hyp

Pre

Fu

[PS-OVER: p=.018] [BDI: p=.032]

Programme’s Acceptance: Attendance and Satisfaction Variables

Results Descriptive data

• Programme attendance rate:

- High: 88% on 9 or ↑ sessions (mean:11 sessions)

- Dropped out: 8% (4 mothers < 4 sessions)

4

5

6

7

Methods' usefulness(1-7)

4

5

6

7

Strategies' usefulness(1-7)

• Programme satisfaction:

- IY approach to change behaviours appropriate (29%) or very appropriate (71%)

- High satisfaction with the sessions’ content and program components (methods, strategies, leaders, group)

Discussion

Main Conclusions

II. Maintenance of gains from 6 to 12-month after baseline (small ES):

• Coaching effect faded out and AD/HD behaviours (mothers’ interview)

continued to decrease (sleep effects?)

Discussion

I. Encouraging results, suggestive of significant short-term intervention

effects :

• Children: Reduction of AD/HD behaviours (home, school) [medium ES];

marginal increase of social skills (only at home – target context)

• Mothers: Improvement of positive parenting, sense of competence and

less dysfunctional practices [medium to large ES]

Main Conclusions

Discussion

IV. High acceptability of IY model

Preliminary evidence of IY as a promising:

P

Early preventive intervention option for

Portuguese children/mothers with similar characteristics

III. Similar changes for both high and low-hyperactivity subgroups:

• But High-Hyp improved more regarding AD/HD behaviours, negative

overreactivity practices and depressive symptoms

Strenghts

• First Portuguese study evaluating IY in a sample of preschoolers with AD/HD

behaviours

• Additional support for early psychosocial intervention Charach et al., 2011; Rajwan et al., 2012

• Widely researched intervention model

• Support form a highly skilled and motivated team

• Methodological strenghts: longitudinal study and a subsample of a RCT

multi-methods (observational measure) and multi-informants

blind independent evaluators

inter-rater reliability studies

• Fill in a gap in clinical practice in Portugal Almeida et al., 2012

Discussion

Limitations

• Small sample size (study 3; pre-school teachers and observational measure sample)

• Absence of a control group at T3 and a normative group

• Sample socioeconomical characteristics and higher education

• 80% of the study took place in a university-based context

• Mothers perceptions and reporting bias

• Heterogeneous sample: different risk levels (limitation?)

• Psychometric properties of some measures (low internal consistency )

• Programme barriers

Discussion

Cautious Generalization

(sample characteristics; not diagnosed children)

Implications

For Research

• Data replication (different contexts and populations)

• Larger randomized sample with longer follow-up periods:

mediators (key ingredients ?) and moderators of change (for whom and in what

conditions ?) Gardner et al., 2010

• Analysis of psychometric features of some measures (Portuguese populations)

• Intervention integrity study (facilitator’s adherence to protocol)

• Directly recruit fathers - larger sample sizes (Fabiano et al., 2012)

• Compare IY with usual care: What is more cost-effective in the long run?;

or with other IY set of programmes: Additional benefits?

Impllications

Lessons Learned: Intervention and Policies

Impllications

• Early identification (community settings): even low-hyp children

• Disseminate effective early intervention

• Investment in training and supervision (fidelity process)

• Longer version (flexibility): reinforce Coaching parenting skills

• Promote continuous support after the end of the programme

• Monitor children with more severe problems

IY Basic Parent Programme intervention tested in a portuguese sample: 14 + 2 Sessions

(2001 version; with some content adjustments, tailored to AD/HD needs and characteristics)

3 de dezembro, 2013

4.2 Resultados: Comportamentos de PH/DA - casa

Pós-FU1-FU2: Efeito não-significativo Tempo, F(2,36) = .498, ns

4.2 Resultados: Comportamentos de PH/DA – casa e escola

Pós-FU1-FU2: Efeito significativo Tempo, F(2,33) = 6.950, p<.01, Effect size partial ɳ2= .263

Pós-FU1-FU2: Efeito não-significativo Tempo, F(2,30) = 2.062, ns